Gulhan Kurtoglu Celik  ( Department of Emergency Medicine, Ataturk Training and Research Hospital, Bilkent Yolu 3. Km, Ankara, Turkey. )
Nurettin Ozgur Dogan  ( Department of Emergency Medicine, Ataturk Training and Research Hospital, Bilkent Yolu 3. Km, Ankara, Turkey. )
Gul Pamukcu Gunaydin  ( Department of Emergency Medicine, Ataturk Training and Research Hospital, Bilkent Yolu 3. Km, Ankara, Turkey. )
Zeynep Saral Ozturk  ( Department of Emergency Medicine, Ataturk Training and Research Hospital, Bilkent Yolu 3. Km, Ankara, Turkey. )
Tugba Atmaca Temrel  ( Department of Emergency Medicine, Ataturk Training and Research Hospital, Bilkent Yolu 3. Km, Ankara, Turkey. )
Alp Sener  ( Department of Emergency Medicine, Ataturk Training and Research Hospital, Bilkent Yolu 3. Km, Ankara, Turkey. )
Havva Sahin Kavakli  ( Department of Emergency Medicine, Ataturk Training and Research Hospital, Bilkent Yolu 3. Km, Ankara, Turkey. )

Objective: To assess behaviours and attitudes of residents toward giving news of death in emergency department and other departments.
Methods: The study was conducted between 1st and 7th December, 2012, in an urban hospital in Ankara, Turkey. It used a questionnarie that was filled by 100 residents from different disciplines of medicine. Categorical variables were analysed with Chi-square and Fisher\'s exact tests and continuous variables were analysed with Mann Whitney U test. The level of statistical significance was set at 0.05.
Results: The most difficult cases to notify were those of unexpected and sudden deaths (n=51; 51%) followed by deaths of children (n=36; 36%). While 60% (n=60) of the study group reported a need for training in this area, but there was no association between having difficulty in notifying a death and expressing the need for training (p=0.187). Residents who had difficulty in notifying death informed the patient\'s close ones more often during resuscitation (p=0.049) and requested for security staff more often during the final briefing compared with the group that did not express having difficulty (p<0.001).
Conclusion: Notifying death is still a challenging issue in medicine. Instead of educational efforts, security measures may be more beneficial and comforting for residents who have difficulty in conveying the news.
Keywords: Emergency medicine, Truth disclosure, Death. (JPMA 64: 390; 2014).

Sudden and unexpected deaths usually shock survivors, parents and other relatives of the victim. Therefore, death notification is one of the difficult aspects of emergency medicine and other branches of medicine. The degree of reactions of the close ones are related to how independent, autonomous, and distinctive the decreased was when he or she died.¹
In acute emergency care settings, death is more common and conveying death news is a stressful event for all healthcare professionals, even for the experienced physicians. Medical and nursing staff usually receive little training or preparation for delivering such news.^2,3 Some educational programmes and teaching modules were developed about giving death news, which include different skills, videotapes of family notification and simulations like resident role play experiences.⁴
While most of the emergency physicians find death notification to be emotionally draining,³ it is inevitable for physicians and appropriate notification is necessary for the relatives of the patient. The aim of the current study was to assess behaviours and attitudes of residents toward giving news of death in emergency and other departments.

The prospective, cross-sectional study was conducted between 1st and 7th December, 2012 in an urban healthcare facility, which is a 400-bed training and research hospital in Ankara, Turkey. The study protocol was approved by the institutional ethical review board. At the time of the study 124 residents were working in the hospital. A 21-item questionnaire was delivered to all those residents. The survey included questions about residents' department and work experience; factors that make death notification educational requirements, sentences and phrases used in notifying of death etc (Table-1).

The survey was conducted during face-to-face interviews. The participants were asked to mention only about the death news they had given personally as the primary physician of the patient.
All statistical analyses were performed by using SPSS 15.0. Kolmogorov-Smirnov and Shapiro Wilk tests were used to analyse the normal distribution of the variables. Continuous variables were analysed using Mann Whitney U test and expressed as median (interquartile range), and categorical data was analysed for significance using the Pearson chi-square and Fisher's exact tests. A p value <0.05 was considered statistically significant.

Of the 124 questionaries distributed, 100 (80.6%) residents completed the process. Of them, 64 (64%) were males and 36 (36%) were females. The mean age of the respondents was 26.35±2.4. Twenty 20 (20%) of them were training in emergency medicine, while 46 (46%) were training in surgery specialties and 34 (%34.0) were training in medical specialties. Overall 92 (92%) residents had experiance of verifying death. In the study sample, the number of years worked as a medical practitioner ranged from 1 to 10 years, with a median of 3 years. Some questions related specifically to death notification (Table-2).

Overall, 65 (65%) residents stated that, they had difficulty in notifying death, while 35 (35%) did not have such difficulty. The most difficult cases to notify about were unexpected and sudden deaths ( n=51; 51%), followed by deaths of children (n=36; 36%), trauma (n=8; 8%) and other cases (n=5; 5%). While 60 (60%) residents favoured a need for training in death notification, there was no association between having difficulty in notifying death and expressing need for training (p=0.187). The difficulty of giving the news of death was not associated with the number of years worked (p=0.184).
While 64 (64%) residents were comfortable giving the news of death unaccompanied, 36 (36%) residents would prefer having residents, attending physicians or social workers around at the time. Also, 84 (84%) residents preferred security staff to be present, due to security reasons. Residents who had difficulty in notifying death, informed the patient\'s close ones during resuscitation more often (p=0.049) and requested more security staff during the final briefing compared with the group that did not express having difficulty (p<0.001). They also introduced themselves to the attendants at the notification scene more often (p=0.047).
The place of the notification was also asked about, and 84 (84%) residents preferred "in front of the resuscitation room/operating room/intensive care unit", 11 (11%) would prefer to give the news in "another room" and 5 (5%) residents in a room designed for psychosocial support. The statement that was used the most often to convey the news was "My condolences" (n=43; 43%), followed by "We lost the patient" (n=30; 30%) and "We did everything we could, but could not succeed" (n=24; 24%).
The residents at the emergency department would give information about being an organ donor more often to relatives at the notification scene (p=0.003). This relationship was not associated with the number of years worked (p=0.480).

Death notification is an integral part of medicine. However, death notification skills are rarely taken into consideration in daily practice. Hearing that a loved one has died suddenly is a difficult experience, and delivering that message and providing support to the family will never be easy.⁵ In emergency departments, death is often unexpected, and emergency physicians usually don\'t have training on death notification skills.⁶
In a study that involved 79 physicians, 61 per cent respondents found their most memorable patient death to be emotionally distressing. Accordingly, 26 per cent reported recent personal bereavement due to a patient death.⁷ In our study, the majority of residents had difficulties in giving the death news, and also no association between work experience and having difficulty was found.
Emergency physicians frequently experience unexpected deaths of their patients. Giving the bad news in the emergency department usually occurs without a previously established physician-patient care relationship. There are some reasons why it may be more difficult for physicians to tell the relatives about sudden and unexpected deaths. A study explained the difficulties of giving the news of death as follows: lack of training and experience, fearing of expressing their emotions, fear of giving inaccurate answers and being unfamiliar with survivors\' reactions.⁸ A small number of residents had formal education about death notification in our study (20%) and this might explain why the group was generally unprepared in the event of a sudden death. To address this need, an educational intervention method (GRIEV-ING) was developed which demonstrated to improve the qualifications of emergency medicine residents in death notification.⁹
Training needs for death notification were investigated in several studies. One study showed changes in approaches of physicians after an educational programme was provided. After the programme was established, delays in giving information about the medical condition of the patients were decreased, and the relatives felt adequately informed about the latest status of their patients.⁵
Another study demonstrated in their questionnaire-based survey that 94% of emergency physicians reported a need for training in this area, but less than half received any training during medical school or residency.³ In our study, 60% of residents declared the need for training, but there was no association between expressing training need and difficulty in giving the news of death. During resuscitation period, the frequency of briefing the patients\' close ones was found higher in the group that expressed having difficulty in death notification. This might be related to the fear of reactions of patients\' close ones. Therefore, security measures gain importance for residents to feel more comfortable at the notification scene.
One of the most difficult aspects in death notification is the death of a child. Also in our study, death of a child was found to be one of the most difficult cases to notify about. According to a study, the processes and protocols surrounding the death of a child in the emergency department are under-addressed and under-studied issues related to end-of-life care. Death of a child involves parents, other members of family, healthcare professionals, day-care or school personnel, nurses and social workers. Therefore, addressing the needs of family members is related to their emotional, spiritual and cultural levels.¹⁰
In the case of death at healthcare facilities, organ donation is an important topic to evaluate. Many physicians feel uncomfortable with involvement in the donation process and attitudes towards brain death have been shown to impact on the organ donation process. Positive attitude was significantly associated with increasing age, higher professional status and was most prevalent amongst intensive care unit (ICU) staff.¹¹ In our study, we did not find any relationship between higher professional status and giving information about an organ donor. However, residents working in emergency department did not prefer giving any information about organ donation after a sudden unexpected death.
In terms of limitations, the current study was done at one centre and reflected residents\' views of that institution. The study was conducted in a tertiary healthcare facility, and results may be different in primary healthcare centres. Broader multi-centre studies are needed in this area to achieve results that can be generalised.

Although death notification is one of the difficult tasks in medical practice and a part of end-of-life care, many physicians receive little or no formal training about giving the news of death. Need for education about death notification is expressed in many studies, but education alone may not be enough for physicians to feel comfortable. In addition to educational efforts, security measures may be beneficial and comforting to residents who have difficulty in giving death news.

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